The emotional impact of nursing : identifying issues and supporting staff

WILSON, Janet Lynn

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WILSON, Janet Lynn (2017). The emotional impact of nursing : identifying issues and supporting staff. Doctoral, Sheffield Hallam University.

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Sheffield Hallam University Research Archivehttp://shura.shu.ac.uk

The Emotional Impact of Nursing:

Identifying issues and

supporting staff

Janet Lynn Wilson

Published works submitted in partial fulfilment of the requirements of

Sheffield Hallam University for the degree of Doctor of Philosophy on the

basis of Published Work

June 2017

2

Contents

I List of Publications 4

II Abstract 5

III Acknowledgements 7

IV Ethics Statement 8

V Critical Appraisal 9

1. Introduction 9

1.1 Aims and rationale for selection of submitted works……………………...9

1.2 Background…………………………………………………………………..11

1.3 Approach……………………………………………………………………..12

1.4 Key themes…………………………………………………………………..15

1.5 The emotional health of staff in healthcare settings……………………..15

1.6 The emotional impact of working with patients at the end of life……….17

1.7 Home services for end of life care…………………………………………18

1.8 Conclusions from the literature…………………………………………….19

1.9 Synthesis of the works as a coherent study………………………….…..19

1.10 Conclusion……………………………………………………………….….22

2. Critical appraisal of submitted works 23

2.1 Empirical Studies……………………………………………………….……23

2.1.1 Reflexivity………………………………………………………………..…23

2.2 Literature Reviews………………………………………………..….……..31

3. Original independent contribution 37

3.1 The impact of shift patterns on healthcare professionals………….…..37

3

3.2 Effects of patient death on nursing staff; a literature review and

account of the research into ward staff experiences of patient death…..38

3.3 Working with bereavement: a practical guide…………………………39

3.4 The awareness of emotional intelligence by nurses and support

workers in an acute hospital setting………………………………………..40

3.5 Professional socialisation and bullying behaviours in nursing………41

3.6 Service evaluation of a hospice at home service……………………..42

3.7 Conclusion………………………………………………………………...43

References…………………………………………………………………………....44

Appendix 1: Origins and progression of the programme of study………………56

Appendix 2: Summary of submitted publications ………………………………..58

Appendix 3: van Manen's approach to data analysis as used in the empirical

study on ward staff responses to patient death……………………………….….65

Appendix 4: Copies of submitted publications…………………………………….67

4

I. List of Publications

Ref No

Details of Publication My role in publication preparation

1 Wilson J. (2002) The impact of shift patterns on Health Care Professionals. Journal of Nursing Management, 10, 211-219

Sole author

2 Wilson J, Kirshbaum M. (2011) Effects of patient death on nursing staff: a literature review. British Journal of Nursing 20(4) 239-241

I was the lead author of this paper taking the lead on all aspects of its preparation with some input from the co- author

3 Wilson J. (2014) Ward Staff experiences of patient death in an acute medical setting. Nursing Standard. 28(37) 37-45

Sole author

4 Wilson J. (2014) The Awareness of Emotional Intelligence by Nurses and Support Workers in An Acute Hospital Setting. Journal of Health Sciences. 2(9) 458-464

Sole author

5 Wilson J. (2014) Working with Bereavement. A Practical Guide. Basingstoke, Palgrave Macmillan

Sole author

6 Wilson J., Steers J., Steele K., Turner J., Tinker A. (2015) Evaluation of Community based Palliative Care and a Hospice at Home Service involving the use of Focus Groups. End of Life Journal. Published Online First. [10August 2015] doi: 10.1136/eoljnl-2015-000004

I was the lead author of this paper taking the lead on all aspects of its preparation with input from the other members of the research team

7 Wilson J. (2016) Professional Socialization in Nursing; Experiences of New and Established Nursing Staff in response to patient death. American Research Journal of Nursing. 2(1) 4-8

Sole author

8 Wilson J. (2016) An Exploration of Bullying Behaviours in Nursing: a review of the literature. British Journal of Nursing 25(6) 2-5

Sole author

5

ll. Abstract

These publications relate to the emotional impact of nursing and result from three

separate empirical studies conducted during the years 2002 to 2016, in the UK. Each

study was qualitative, specifically using phenomenology to investigate the lived

experiences of staff working in healthcare.

Eight publications are included in this submission. Four journal articles report on aspects

of two studies, three review the relevant literature and the final publication is a book

developed from one of the studies.

Two studies specifically focus on the experiences of nursing staff; the 2002 study

focussed on their experience of shiftwork and the 2014 study explored nursing staff

responses to patient death. The third empirical study involved a range of healthcare staff,

patients and carers and was an evaluation of a hospice at home service.

The contribution to knowledge includes:

Identification of the social and emotional issues of working shifts, providing advice and

guidance for managers of this aspect of nursing work

The exploration of specific needs of nursing staff in response to patient death in terms of

education and support. This resulted in curriculum changes in nurse education to cover a

range of issues including grief reactions, disenfranchised grief, emotional intelligence and

professional socialisation.

The book was developed as a result to provide an accessible handbook for health and

social care staff working with those at the end of life and their bereaved family and friends

in a range of settings.

A methodology using focus groups with a range of stakeholders was developed for the

evaluation of a hospice at home service. This has been recommended as the preferred

6

model for evaluations by the hospice at home association. The range of stakeholders

contributing was wider than in previous studies. From the evaluation, further funding and

an extension to the service was secured by the organisation.

7

lll. Acknowledgements

I would like to extend my sincere and heartfelt thanks to many people who have supported

and encouraged me in my research and publications over several years. I am grateful to

Dr Jane Clayton and Professor Marilyn Kirshbaum who supported and guided me through

some of the earlier publications and my co-authors and researchers for the hospice at

home evaluation study; Julie Steers, Kath Steele, Dr Jim Turner and Alison Tinker.

I am extremely grateful for support and direction from my supervisor Professor Ann

Macaskill who has wisely guided me through this process.

I am also very grateful for the ongoing support of several friends both professional and

personal who have been a constant source of encouragement.

8

lV. Ethics Statement

All of the research studies linked to this thesis have received full ethics approval from the

appropriate Research Ethics Committees at the healthcare trusts where the research was

conducted.

9

V. Critical Appraisal of published works

1. Introduction

1.1 Aims and Rationale for selection of submitted works

This critical appraisal covers aspects of my writing and research within the area of adult

nursing. The submitted works represent the development of my research and writing

concerning the emotional impact of nursing, particularly in situations such as patient

death. The papers identify and explore relevant issues such as staff working hours, peer

pressures, educational needs, coping strategies and how staff can be supported in these

circumstances and work situations. The core focus of my work is that of applied research

aimed mainly at clinical staff and finding solutions to practical problems in order to support

them in their clinical practice and promote a high standard of patient care. Figure 1

overleaf shows how the empirical and literature review research links to the published

papers.

This document contains three sections. This section is an introduction giving background

information, explaining the rationale for the approach used and the development of my

research themes. This section also contains a synthesis of my work as a coherent study.

Section two provides an overview and critical appraisal of each publication and the final

section discusses the key original contributions to knowledge and impact of each

publication submitted.

An account of the origins and progression of the research which underpins the eight

publications is set out in Appendix 1.

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Figure 1

STUDIES OUTPUTS

Empirical Studies

Literature reviews

Empirical study: Impact of shift

patterns on Healthcare

professionals (2002)

Publication: Literature Review

(2002)

Conference presentations of

Study findings: (2003)

Empirical study: Ward staff

experiences of patient death

(2014)

Publication: Literature review

(2011)

Publication: Research

findings (2014)

Publication: Professional

Socialisation (2016)

Publication: Emotional

Intelligence (2014)

Empirical study: Service

Evaluation of Hospice at Home

services (2015)

Publication: Service

evaluation report (2015)

Literature review:

Bullying (2016) Publication: Bullying

Behaviours in Nursing (2016)

Literature review:

Effects of Patient death

on nursing staff

Literature Review:

Working with

Bereavement (2014)

Book: Working with

Bereavement (2014)

Conference presentations of

Study findings: (2011-2014)

11

1.2 Background

Nursing is a complex occupation which takes place in many settings and includes a wide

range of activities. It involves both physical and emotional aspects of care for patients and

their carers (Sellman, 2011).

Emotional aspects of care are referred to as emotional Labour; a concept first developed

in 1983 by Hochschild, and involves staff acting out behaviours in order to convey to

others their care and concern. For nurses this can involve smiling and talking in a calming

voice even though they may be anxious or worried (Smith, 2012). It is used to make

patients feel safe and is part of the normal routine of nursing (Smith & Gray, 2001). This

feature was identified as being particularly required when staff care for patients in stressful

situations such as those nearing the end of life (James, 1992) and those in pain or

experiencing loss (Smith, 2012).

Within nursing, emotional intelligence is a feature that has been identified as being

essential for this work. Whyte (1997) wrote that the nurse who is emotionally intelligent is

one who can work in harmony with both their thoughts and their feelings. Freshwater and

Stickley (2004) consider that emotional intelligence is fundamental to the act of caring.

Smith (2008) states that student nurses need to understand the emotional nature of

nursing, have emotional skills in order to deliver competent nursing care and develop

emotional intelligence in order to deal with chaotic working environments.

Many nurses work shifts with increasing workloads and care for people who are very ill

and some of whom die. It has been identified that sources of stress for nurses include

high workloads, interpersonal issues, shift work, caring for patients at the end of life,

demands from relatives and carers and unsupportive management (Gamma, Barbosa &

Vieira 2014; Happell et al. 2013). The Health and Safety Executive (2016) identified that

those working in health and social care activities have a prevalence rate for work related

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stress of 2,020 cases per 100,000 workers which is considerably above the national

average for all industries of 1,230 cases per 100,000 people employed.

These emotional aspects of nursing if not managed successfully can result in adverse

effects on nurses, the organisation and on patients and carers. The possible effects for

nurses is that their physical and psychological health may suffer and the organisation may

be subject to high staff turnover and absenteeism. This can result in patients and carers

experiencing a low level of care from staff lacking commitment to their work and poor

continuity of care due to staff turnover and low staffing levels (Happell et al. 2013).

Working in clinical practice made me very aware of difficulties nurses face in their work

and the lack of support available. This was particularly apparent in challenging situations

such as end of life care and the death of patients. The rationale which underpins my

research programme is the emotional welfare of nursing staff, enabling them to develop

resources to support themselves to deal with challenging clinical situations. By caring for

and supporting staff, then both patients and the organisation benefit as well as the staff

members themselves. If staff are cared for and well supported then they are likely to feel

committed and loyal to the organisation and they will provide a high level of care to the

patients and carers with whom they work.

1.3 Approach

The studies underpinning this PhD adopt an interpretivist approach. The focus of the

research is to build understanding in terms of the different meanings that people derive

from their experiences (Denzin and Lincoln 1994). The interpretivist approach assumes

that reality is socially constructed by human actors and this includes researchers. In

adopting this approach the aim is to develop understanding as in this research

13

programme, rather than collecting "facts" which can be used to provide explanations as in

positivist methodologies.

A major characteristic of this research is that it is conducted in the field; it is not an

artificially created environment as found in laboratory experiments. It cannot be measured

or quantified and verified by independent observers with the researcher holding the

position of detached observer, therefore a positivist approach would not be suitable for this

type of research.

The data for these studies consists of accounts of individual ward staff’s responses and

those of hospice at home stakeholders in specific situations that are real and have

meaning to the individual (Streubert and Carpenter 2011). The aims of the studies to

discover the lived experiences of the participants determined the approach taken. As

phenomenology strives to describe experiences as they are viewed and interpreted by the

participants themselves (Denzin and Lincoln 1994) this was the methodology of choice.

While a broadly hermeneutic phenomenological approach inspired by Heidegger was

adopted, the specific procedures follow van Manen's description of conducting

phenomenological research (van Manen 1984).

Ethnography was considered as a methodology as this also seeks to explore the individual

experiences of the participants in the culture and context of the environment where the

research is undertaken. However it was decided that phenomenology would offer a more

in depth understanding of the phenomenon under investigation.

Within phenomenology a number of approaches exist. The studies which form the basis of

this PhD utilised van Manen's approach (1984). In his paper titled, 'Practicing

Phenomenological Writing' (1984) van Manen identifies four key elements to his approach;

turning to the nature of the lived experience, existential investigation, phenomenological

reflection and phenomenological writing (p42). These elements involve the following:

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1. Turning to the nature of the lived experience involves the researcher seeking to

make sense of a particular life circumstance and focussing on what it means to the

individual to experience the specific phenomenon under study.

2. Existential investigation involves a combination of searching the current literature

for records of descriptions of the phenomenon, utilising the personal experiences of

the researcher and obtaining descriptions from research participants

3. Reflection is the thoughtful comprehending of what gives an experience its special

significance, to discover the essence or core of the experience.

4. Phenomenological writing consists of the ability to be sensitive to the subtle

undertones of the language used. The writing is organised around themes and

reflection is an integral part involving the interrogation of the phenomenon and

rewriting as various levels of questioning of the phenomenon are worked through.

The strength of van Manen's approach to the collection and analysis of data is that it

includes a stage whereby the researcher returns to the participants following initial

analysis of the data to check that the interpretations made by the researcher were also

those of the participants. This was very important as the researcher has knowledge and

experience of the phenomena being studied and wanted to ensure the findings from the

data analysis were those of the individual participants. The checking with participants

involved asking them to clarify words relating to their emotional responses. For example if

they said they felt upset they were asked to explain what they meant by this word. This

led to participants giving more details of emotions they experienced such as anger,

sadness or frustration.

Other methods of thematic analysis could have been used such as framework analysis

and IPA but these do not involve asking the participants to categorise the findings as van

Manen does in his approach. Following the design developed by van Manen (1984 and

15

1990) and used by Callaghan (2010) and Standing (2009), the data collection and analysis

was carried out in two stages. Following the first interviews there was an initial analysis of

the transcripts to obtain pertinent and commonly reported phrases. These were written on

cards and during the second interviews, participants were asked to verify these and

identify the ones that are pertinent or relevant to them. They were also asked to sort the

various phrases into groups. These were further scrutinised by the researcher along with

the transcripts to confirm the groups or preliminary themes. These were then reviewed by

the researcher and the essential themes derived.

1.4 Key themes

The publications presented here primarily focus on particular aspects of nursing work

which have an emotional impact on staff. One publication is an evaluation of a service

providing end of life care with recommendations for the future resulting from interviews

with service users and healthcare staff involved in the running of this service.

1.5 The emotional health of staff in healthcare settings

There is considerable evidence to suggest that investment in healthy working practices

and the health and wellbeing of employees improves productivity and is cost effective for

both organisations and the wider society (Coats & Max, 2005; Dunham, 2001; Foresight

Mental Capital and Wellbeing Project, 2008). Measures to safeguard employee mental

wellbeing could help businesses and organisations retain staff with the skills and

experience necessary for sustaining business performance in the long term. The

document 'Promoting Mental Wellbeing through Productive and Healthy Working

Conditions' published by the National Institute for Health and Clinical Excellence (NICE) in

2009 listed recommendations for employers. These are; adopting an organisation-wide

16

approach to promoting the mental wellbeing of all employees and ensuring that the

approach takes account of the nature of the work, the workforce and the characteristics of

the organisation. It also should ensure that systems are in place for assessing and

monitoring the mental wellbeing of employees so that areas for improvement can be

identified and risks caused by work and working conditions addressed.

In the National Health Service (NHS) Health and Wellbeing Final Report (Boorman, 2009)

there are recommendations aimed at NHS Trusts to implement the guidance from NICE

(2009) on Promoting Mental Health and Well-being at Work. This document recommends

that all trusts should provide a range of additional staff health and well-being services

targeted at the needs of their organisation. To do this they will need to assess the specific

needs and requirements of their staff and determine the services staff wish to see

provided.

Healthy Lives, Healthy People: Our Strategy for Public Health in England was a Her

Majesty's (HM) Government white paper published in 2010. This is a strategy for Public

Health in England focusing on health and wellbeing throughout life. This document states

that there is a need to provide evidence and data that will raise awareness among

employers of the case for investing in the health of employees.

Dame Carol Black's review of the health of Britain’s working age population (Department

of Work and Pensions and Department of Health, 2009) highlighted that working age ill

health was costing England £100 billion a year. Key issues identified include early

intervention, prevention and proactive responses such as health-promoting workplaces,

better mental health and employment outcomes, and lengthening healthy working lives.

My research aims to explore how the emotional health of staff is supported and managed

by employers and by healthcare staff themselves. A major focus is the identification of the

17

emotional impact of their work on nursing staff, their recognition of this and how they

manage this aspect of their work.

1.6 The emotional impact of working with patients at the end of life

It has long been acknowledged that the death of someone known to an individual has an

emotional impact on the person experiencing the bereavement (Kubler-Ross 1973; Parkes

1975). There has been research over many years identifying the impact of bereavement

on individuals. This has developed from Freud's work on melancholia (1949) through to

recent theorists who have identified the importance of making sense of the death

(Neimeyer, 2001) and the work of Stokes (2009) on resilience in children following the

death of a parent. One way of making sense of death involves the bereaved person

creating a story enabling them to integrate the memory of the dead person into their

ongoing life (Walter, 1996).

The death of a patient is an event most, if not all nursing staff experience as part of their

work in a healthcare setting. The role of caring for a patient who is dying and supporting

family members at this time has been described as one of the most demanding roles in

healthcare (Loftus, 1998). A literature search at the time of the study identified that the

focus of much of the research at this time was the responses of staff working in specialist

palliative and long term care settings, and oncology or intensive care units (Irvin, 2000;

Meaders & Lamson, 2008; Rickerson, Somers, Allen, Lewis & Strumpf, 2005,). In these

settings there was an emphasis on end of life care and not as in acute hospital settings on

recovery and discharge home.

The focus of my research in this area is to explore the responses of nursing staff to patient

death in acute hospital settings where the emphasis is on recovery and discharge home

and not on palliative and end of life care.

18

1.7 Home services for end of life care

Hospices and other providers of end of life care are required to develop services which

aim to give choices to patients in this situation and their families and also improve the

quality of the care they receive. Most terminally ill people would prefer to die in their own

home (Eyre, 2010; Stevens, Spencer-Grey, Heller & Komaromy, 2009), however only

about a quarter of these people do so. This has been found to be due to a range of factors

including the quality of family support, and the availability of social and healthcare support,

including home based palliative care (Capel, Gazi, Vout, Wilson & Finley, 2012; Sheppard,

Wee & Straus, 2011,).

Providing palliative care in a home environment can be challenging for both the health

professionals involved and for the patient and their family. This can range from the

psychological impact on the family in terms of stress and disruption of their daily life (Eyre,

2010) to the variety of health professionals which may be involved. The healthcare staff

may include community nurses, general practitioners, hospice staff, Macmillan and Marie

Curie nurses and other specialist nurses. They will all be required to have a distinct and

co-ordinated plan of care so the patient, family and professionals are all clear on their

specific roles and responsibilities and who to contact for specific issues (Jarrett & Maslin-

Prothero, 2008).

My research in this area focusses on the evaluation of a hospice at home service from the

viewpoint of both care providers including community nurses, general practitioners and

specialist nurses from Macmillan and Marie Curie services and from patients and carers

who use this service.

19

1.8 Conclusions from the literature

The publications presented here contribute to addressing gaps and weaknesses in the

existing literature through addressing the following issues

The emotional wellbeing of staff in being supported in their work and their

awareness and management of their emotional responses to work

situations. (publications 1, 2, 3, 4, 5, 7, & 8)

The emotional impact of working with patients at the end of life and

supporting the bereaved in acute hospital settings. (publications 3, 4, 5, & 7)

Differing perspectives from staff and service users of home services for end

of life care (publication 6)

1.9 Synthesis of the works as a coherent study

I am primarily an inquisitive practitioner in nursing wanting to contribute to the

development of evidenced based practice and find empirical solutions to practical

problems. With the new Sheffield Hallam University (SHU) strategy of applied research I

have come to see myself as an applied researcher as the papers and reports submitted all

relate to clinical practice. There is an emphasis in my work on supporting staff to develop

their own emotional skills and knowledge to enable them to take care of themselves and

as a result provide a good service to patients.

The research into shift work in nursing was conducted whilst I was working in the practice

development department of a large teaching hospital and was involved in studies relating

to the skill mix of nursing staff and workload management. Many of the areas where the

studies on workload were carried out involved shift work and being interested in the

wellbeing of staff in healthcare I wanted to explore the physical, social and psychological

impact of shift work on nursing staff. The study was a qualitative one using a

20

phenomenological methodology as I wanted to explore the personal experiences of shift

work for the participants. I had spent several years working shifts in hospital settings and

therefore had personal knowledge and experience of this aspect of nursing work. Staff in

the area where this study took place were considering changing the length of shifts at this

time and the study interviewed participants before the shift changes and then three

months after the changes to ascertain the physical, emotional and social effects of the two

systems.

As well as the shifts staff worked I recognised that there were other aspects of nursing

work which had an impact on the emotional wellbeing of staff. Having worked clinically in

medical wards I was mindful of how the death of a patient could impact on staff and was

interested to investigate staff responses to this event and identify how they managed this

situation in a large acute hospital setting.

As highlighted earlier the literature review identified that most research into this topic took

place in specialist units such as palliative care centres (Fisher, 1991), oncology wards

(Aycock & Boyle, 2008), and intensive care units (Meaders & Lamson, 2008). I wanted to

identify the specific issues for staff working in an acute setting where the emphasis was on

patient recovery and discharge home rather than end of life care.

The study which resulted from the literature review used a Heideggarian

phenomenological approach to gather and analyse data. Nursing staff were interviewed

about their experiences following patient deaths and themes were identified of responses,

influences and support.

From this study there were particular findings I wanted to explore further and one of these

was the awareness and use of emotional intelligence by staff. During the study above,

none of the participants mentioned this concept however some demonstrated they had

this quality in their reporting of how they managed their emotions following patient death.

21

Some staff did not appear to have developed skills or knowledge of emotional intelligence

and this paper was designed to inform staff about this concept and help them identify how

they could develop emotional intelligence and use it in their work.

Another concept identified from the original research was that of professional socialisation.

It was found that newly qualified nurses had assumptions of how they should behave in

the work setting following a patient's death which they felt would be acceptable to more

established staff members. However the study found that the newer staff members

assumptions were not always correct and in fact several established staff members

behaved in a manner opposite to that assumed by the newer staff to be the acceptable

way of responding. This finding led to an interest in this phenomenon and the exploration

of this concept in healthcare resulted in the published paper focusing on this aspect of the

research.

Whilst searching the literature for the article on professional socialisation I found several

articles referred to bullying behaviours by nursing staff with the aim of forcing others to

conform to certain practices and behaviours in a unit. There was a link identified between

professional socialisation and bullying. This led me to publish a paper reviewing the

literature on bullying behaviours in nursing.

From the research study I identified that there was a lack of knowledge and awareness of

several aspects of patient death in terms of staff managing this emotionally for themselves

and recognising influences such as professional socialisation and disenfranchised grief.

This led me to identify a need for a text for staff to use both in caring for patients and their

families, supporting colleagues and also in developing their own skills of resilience and

self-care.

The development of the book 'Working with Bereavement' started from the literature

review which prompted me to look at other evidence of best practice in working in this

22

area. This book provides evidence based practice from a library based research study of

systematic reviews and complementary work already done in this area.

As a result of my knowledge and experience in end of life care and bereavement I was

asked along with colleagues to undertake an evaluation of a hospice at home service in a

local town. This was a qualitative study consisting of focus groups with a range of

stakeholders and data analysis used a framework approach to categorise the responses.

My knowledge and skills in this area both of the specific topic and of performing qualitative

research were utilised in this study to gain the individual experiences of the various

stakeholder groups of healthcare staff and service users.

1.10 Conclusion

This section as well as including a background to my research has given details of how my

research outputs have developed. It also explains how the publications have followed on

from each other, all with the central theme of identifying the personal lived experiences of

nursing staff and supporting them in their roles with a focus on the emotional components

of their work

23

2. Critical appraisal of submitted works

This critical appraisal is divided into two sections, one covering the empirical studies and

the second covering the literature reviews. Summaries of each of the publications are in

appendix 2.

2.1 Empirical studies

There are three empirical studies which contributed to seven of the publications submitted.

As discussed above, phenomenology was used as an approach in the studies on shift

patterns and responses to patient death to obtain the lived experiences of the participants.

This choice enabled the perceptions of individuals to be identified along with accounts of

their experiences thoughts and feelings in relation to their encounters with the

phenomenon being studied.

2.1.1 Reflexivity

In carrying out research of any kind there is an assumption made that the researcher is

investigating something outside of themselves. In the case of phenomenology, the

assumption is that the knowledge being sought cannot be gained solely through

observation. However, it can also be claimed that a researcher cannot research something

of which they have no experience or from which they are completely isolated. All

researchers are to some degree connected to, or part of, the object of their research

(Kvale 1996). This leads to questions concerning the process and results of the research

relative to the impact of the researcher’s presence and influence. In the thought processes

of any researcher, subjectivity is an inherent feature and this can affect the planning, data

collection, analysis and the interpretation of results of the research.

24

Reflexivity is the continuous process of self-reflection which researchers carry out in order

to become aware of their actions, emotions and perceptions in relation to their research

(Hughes 2014). The role of reflexivity is to improve the transparency of the subjective role

of the researcher and results from this process can allow the researcher to control biases

and make changes to improve the credibility of their findings (Finlay & Gough 2003).

Reflexivity is seen as being of great importance for social research where the link between

the researcher and research setting is close, and the subjects of the research study can

be influenced by the researcher in the process. There is a requirement of subjective self-

awareness for the researcher in order to identify the lived experience which is present

between the researcher and participant (Finlay 2002).

This is significant in Heideggerian phenomenology, as the researcher is engaged in

constructing the reality emerging from the research through the process of data collection

and analysis. Van Manen (2017) writes that reflection is an integral part of

phenomenological research, that the researcher needs to spend time reflecting on words

used to weigh them for their cognitive meaning and be attentive to insights which may be

realised through both their thoughts and also through writing and rewriting. According to

Finlay and Ballinger (2006) subjectivity is something to be not just acknowledged but

celebrated in qualitative research, and that it can facilitate the exploration of the

perspectives and experiences of the participants (Smith 2006).

The personal history of the researcher, along with their professional and socio-cultural

circumstances, can have a significant effect on which topic and which group of people are

selected for the research. By interaction with the participants, the researcher helps to

construct the observations and interviews that become their data.

A positive feature for participants in the study on nursing staff responses to patient death

was their knowing that I am a nurse and that they could use language familiar to

25

healthcare staff. They did not need to explain terms and abbreviations that are commonly

used. Examples of the terms used by participants were; fatal haemoptysis and the

abbreviation COPD (referring to Chronic Obstructive Pulmonary Disease). Participants did

not need to explain these words as they were aware the researcher knew these terms.

Having worked in environments that appeared to be similar to the one where this study

was undertaken, I could have made assumptions from my past experience, which are not

relevant or applicable to the participants in the study. This could include the defining of

words used, or that the work setting for this study was the same or similar to where I had

worked in the past. In order to counteract this I asked participants for their definitions of

some words used, and did not rely on my own interpretations of what they said. Examples

were to ask participants to clarify what they meant by general terms used to describe their

emotional responses such as 'feeling upset'.

A feature of hermeneutic phenomenological research is that of the hermeneutic circle

(Koch, 1999). Godamer (1990) describes the hermeneutic circle as the fusion of horizons.

This involves the researcher having awareness of and not being attached to their own

prejudices and biases, what he calls fore-structures consisting of the researcher's values,

experiences and background. This results in a dialogical method where the horizon of the

researcher and the participant are combined (Dowling 2004).

I tried to balance how much I asked for clarification with allowing participants to freely talk

about their experiences. I did not want to interrupt them excessively but was also aware I

needed to be clear on some words they used where there was a possibility of ambiguity.

Heideggerian phenomenology suggests that a researcher's knowledge and experience of

the subject area can be beneficial in enabling them to ask pertinent questions of the area

of study.

26

Interviewing participants individually enabled them to contribute their own personal views

without being inhibited or influenced by other participants being present. Open ended

questions enabled the participants to respond in their own words and not limit them to set

responses (Lobiondo-Wood & Haber 2010).

The first study carried out in 2002 concerned the impact of shift patterns and the

publication associated with this was a literature review. The findings from the study were

presented at nursing conferences but not published in a peer reviewed journal. With

hindsight it would have been beneficial to have published this research and could have

added useful knowledge to the empirical studies in this area of nursing practice.

The second empirical study explored ward staff experiences of patient death in an acute

medical setting and was conducted in 2014. Phenomenology was the approach used in

this study focusing on the participant's individual interpretation of their experiences and the

ways in which they expressed them. An alternative method of ethnography could have

been used in this study to explore how people can influence and be influenced by the

groups they are part of and identify shared norms, values, perceptions and behaviours.

Ethnography is concerned with understanding how people interact and behave as part of a

group (Parahoo 2014). Phenomenology was selected as it was the individual personal

experiences which were the focus of this study. However conducting a similar study using

an ethnographic approach could produce new findings which would add knowledge and

have an application to practice in this area.

Individual interviews were used in this study as it was the individual personal experiences

of the participants which was sought and not the collective view of a group of people. The

strengths of using individual interviews were that participants were able to express their

own views and not be inhibited or influenced by fellow participants who may have had

different responses to the questions. A limitation of this type of data collection could be

27

that individuals responded to questions of what they thought was expected of them in their

professional role rather than what they really thought. They also may have omitted some

important aspects which they did not think of at the time of the interview. The use of focus

groups instead of interviews could have elicited other useful information as participants

would have had the opportunity to discuss issues with each other and clarify their views in

a way which is not possible in an individual interview (Parahoo 2014).

The choice of using the method of data analysis described by van Manen (1984 & 1990)

was selected for this study as it involves a second interview with the participants checking

what they meant by certain words and phrases they used. Some other methods of

thematic analysis which could have been selected did not involve checking back with

participants. To ensure the findings included the definitions of the participants as

accurately as possible rather than the researcher's interpretations of words used, the

approach of van Manen was selected. A detailed description of this method of analysis as

used in this study can be found in Appendix 3.

Issues with using this approach included locating the participants for the second

interviews. Following the first interviews, the unit where the study was performed was

reconfigured resulting in some staff moving wards and one person left the trust. Other

issues encountered when trying to apply the phenomenological approach was trying to

find suitable times and locations for the interviews. On several occasions when

appointments were made to interview participants it was found on arrival by the researcher

that due to circumstances of staffing levels or of unexpected emergencies with patients

the interview had to be cancelled and rearranged. Private rooms for the interviews were

generally available although on occasions the interviews had to be relocated if the room

was required for other purposes.

28

This study is differentiated from others looking at staff responses to death in that it did not

take place in a specialist unit such as a hospice, oncology ward or other area focussing on

palliative or end of life care. It took place in a general acute medical ward where the

emphasis is on treating patients and enabling them to be discharged home.

It may be that ward staff caring for patients with other types of chronic illness, such as

heart disease or diabetes, may have different responses to patient death. This study was

conducted at a specific time in a large teaching hospital in the north of England. These

factors could be pertinent to the findings of this study. It could be that a similar study

conducted at a different time in a smaller hospital, or another area of the country, could

result in different findings. This could mean that the findings are not transferable to other

areas of healthcare where patients are cared for with a chronic illness.

This research study had a small number of participants – thirteen - and it is not possible to

generalise the findings to other acute healthcare settings within the UK. However, the

results are indicative of the meaning that ward staff give to their experiences in this setting

regarding patient death.

Some of the findings corroborate those from other studies investigating nurses’ responses

to patient death. It could be that ward staff in other acute hospital settings have similar

responses. The sample size for this study was comparable to similar research studies

using a phenomenological approach.

Twelve of the participants were female with just one male involved in the study. Although

this relates closely to the national average percentages in ward staff of 87% female and

13% male in the UK (NHS Digital 2016), this could result in the findings being biased

towards the opinions of females. Hooper-Dempsey et al (1986) express the view that

women's emotional expressiveness is greater than men’s and that they find it more difficult

to leave work behind them when they go home.

29

According to the Health and Safety Executive (2016), nursing is one of the most stressful

professions, and Llewellyn and Osborne (1990) suggest that this can be a major problem

for women in the caring professions who may worry about their patients after they have

left work. If this study had recruited predominantly males then the findings in relation to

emotional responses may have been different.

All the participants in this study were white; twelve were white British. One was from

another European country and had lived in the UK for many years. White British culture,

along with that of other western societies, emphasises the importance of the individual

over the group (Ryde 2009). Values are built on the rights and responsibilities of the

individual whereas some other cultures emphasise the importance of community and

family, seeing themselves as part of this and not as an individual unit (Ryde 2009). This

could alter how situations are viewed as participants from other cultures and ethnic

backgrounds may have responded differently to patient death than those in this study.

Thirty percent of the participants of this study were under the age of 25 years. This is

higher than the current national average for ward staff in this age range, which is less than

five percent (NHS Digital 2016). Participants in this younger age range are likely to have

fewer significant life experiences and will have worked in this health care setting for only a

limited number of years. This may have affected their responses to the questions asked

and could have impacted on the overall findings.

Further research could contribute to the development of knowledge in this area and

guidance for the implementation of training and services to support staff. The study adds

information to this area of research within a specific setting, group of participants and at a

specific time. The replication of this study at a different time, in a different acute setting

and with participants with a different demographic profile, could add useful knowledge in

30

confirming any similarities or identifying differences. Replication of this study in a similar

setting could also help to support these findings or identify variations.

Since the publication of this study two papers have been found which focus on nursing

experiences of patient death in medical wards. Palese, Patean & Cerne, (2013) studied

unexpected deaths at night in a medical ward in Italy exploring how better surveillance

could be used to identify patients at risk so had a very different focus.

The second paper by Mak, Chiang & Chui, (2013) studied nurses' perceptions of caring for

dying patients in a medical ward in Hong Kong. The findings identified the need for staff

education on bereavement and the requirement for staff support in coping with somatic,

cognitive, behavioural and emotional responses to death. This study supported my findings

in these aspects and demonstrates that although this study took place in a very different

culture there are similar needs identified for staff working in this type of ward environment.

The four publications associated with this study were the literature review, report of the

study and papers on the specific aspects of emotional intelligence and professional

socialisations which were prominent findings from the study.

The third empirical study was an evaluation of a hospice at home service. This study was

distinctive in that it considered the views of a range of stake holders and evaluated the

whole of the hospice at home service.

Focus groups were used for this study. This was in order to utilise group processes to

enable participants to explore and clarify their views. This occurred in discussions

amongst themselves and with the aid of a researcher as facilitator.

Interaction is a key concept in focus groups where data generated can be confirmed,

refuted and discussed in more detail within the group (Addington Hall et al 2007). The

31

potential result of this is to provide a greater breadth of understanding of the topic and the

data can be validated by other members of the group.

Individual interviews could have been used for this study but there would not have been

the opportunity for participants to explore and discuss their ideas as they can in a group.

Some people may feel they can talk more freely in a group and share their views or

experiences however others may feel inhibited and not express their true thoughts or the

group may be dominated by one member inhibiting others from contributing their opinions.

In view of the fact that this study involved a range a stakeholders, focus groups were

divided in to the specific groups in order that participants were with others in the same

area of work or experience such as carers which would hopefully enable them to voice

their opinions in a safe and open environment. The facilitator helped to ensure all the

group members had an opportunity to speak and express their views.

A search for current literature evaluating hospice at home services resulted in very few

articles. Those found explored the views of one group such as carers (Exley & Tyrer,

2005; Jack O'Brien, Scrutton, Baldry & Groves, 2014), differences in referrals from diverse

socio-economic areas (Campbell, Grande, Wilson, Caress & Roberts, 2010) and the

development of a specific service such as crisis intervention (Travers & Grady, 2002). No

studies were found which comprehensively evaluated the service from different viewpoints

of all those involved as either providers or recipients of the service.

2.2 Literature Reviews

Three of the journal articles and the book are the result of reviews of the literature on the

selected topics. Ankem (2008) reports that systematic reviews make a substantial

contribution to healthcare literature and are amongst the most popular types of studies

searched for through library services. A range of 14 types of literature reviews are

32

identified by Grant and Booth (2009). In selecting a review type the aim of the review

must be identified in order to select the most appropriate method. The papers in this

section incorporate elements of systematic reviews and were conducted to systematically

search for and appraise studies and synthesise the research evidence.

Some types of reviews such as a meta-analysis were not appropriate as this method is

specifically aimed at the analysis of quantitative studies. Other types of review could have

been used in these papers, many of which are systematic in their approach but

concentrate on specific aspects which determine their focus.

A mapping review aims to identify gaps in the literature which could have been pertinent

for the topics studied; however a perceived weakness could be a lack of depth in analysis

in relation to processes used to measure quality (Grant and Booth 2009). A narrative

review is mostly aimed at studies using mixed methods and can give a more complete

picture of the topic but can also result in difficulties in trying to integrate qualitative and

quantitative results (Grant and Booth 2009).

The current trend in literature reviews involves a number of stages. Initially the question

needs to be clearly framed and can be developed using the acronym PEO for qualitative

studies. These letters stand for population, exposure and outcome (Khan et al 2003) and

for the review on shift work the population was healthcare professionals, the exposure,

shiftwork and the outcome, impact on staff.

These words and phrases can be used as keywords in searching the literature and

alternatives added to create a search string strategy. Specifying inclusion and exclusion

criteria and creating a search strategy string of keywords is a current convention used in

literature reviews. The range of sources used also needs ot be specified, for example

specific databases, hand searching of reference lists in journal articles, grey literature,

conference proceedings and books (Bettany-Saltikov 2012).

33

The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA)

provides guidelines for conducting database and hand searches and includes a checklist

of items designed to help authors improve their reporting of systematic reviews and meta-

analyses (Moher at al 2009).

A diagram detailing the study selection process usually in the form of a flow chart with the

end result of papers selected is also recommended in the PRISMA guidelines to

demonstrate how the search was refined to the eventual number of studies used in the

review (Moher et al 2009). It is also current practice to include a table of the selected

studies detailing the authors, participant details, sample size, study design, findings and

ethical and quality assessment (Bettany-Saltikov 2012, Moher et al 2009).

In a review of qualitative studies the included studies are often synthesised under

headings of themes. The discussion section generally includes comparisons of different

study findings, ethical and quality issues, applications to policy and or practice,

suggestions for future research and conclusions from the review (Bettany-Saltikov 2012).

In the reviews published and submitted here some of the above trends and current

practice are followed but others are not.

The review of shift work was published in 2002 when the above trends were not commonly

used. This article does not include a clear section on the methodology used, a list of the

searches, how they were refined or a table of the final articles included in the review. The

key words used are identified in the paper and derived from the aims of the review.

Further key words were identified from papers found in the search. In selecting papers to

include in the review, inclusion criteria included qualitative studies and exclusion criteria

included commentaries, review documents and discussion papers. Papers were appraised

using the Critical appraisal skills programme framework. This framework was developed in

the 1990s to provide tools to critically appraise research papers and since that time some

34

minor adjustments have been made to the format (CASP-UK 2017) however details of this

are not included in the article.

If this review was being conducted at the present time then the structure of the article is

likely to be very different from that presented in 2002. There would be a clear section on

methodology detailing the aspects mentioned above and include a diagram of the study

selection process along with a table of the final list of articles used in the review. The

studies were synthesised under headings of several clear themes and the discussion

suggested recommendations when planning and implementing shift patterns.

Although this study is likely to have been written in a different format and include more

details of the methodology if written today, this review was published in a peer reviewed

professional journal and it is still being quoted in recent publications on shift work (Lin,

Liao, Chen & Fan, 2014; Peters, de Rijk, Engels, Heerkens & Nijhuis, 2016; von Treuer,

2014). This indicates a contribution to knowledge and that the findings from this review are

still of benefit to researchers and professionals involved in the study and organisation of

shift patterns in healthcare settings.

The literature review on the effects of patient death was published in 2011and there was a

clear question stated in the article with key words identified from the words used in this

question. This article has a section titled search strategy where the methodology of this

systematic review is described with details of the study selection process.

With hindsight, including a diagram in the form of a flow chart detailing the study selection

process could have helped illustrate this process more clearly to the reader of this article.

17 studies were identified for inclusion in this review and a table detailing these would also

have been a useful addition to this article. Themes were identified from the articles in the

review and the discussion includes implications for practice and for future research.

35

The article on bullying behaviours in nursing published in 2016 follows a very similar

format to the article on the effects of patient death on nursing staff. These two articles

were both published in the British Journal of Nursing and followed the conventions of

structure and layout of other literature reviews found in this publication.

The section titled 'search strategy' details the methodology used in terms of key words

derived from the study question, databases used, inclusion and exclusion criteria and the

study selection process. As with the previous article a flow diagram detailing the study

selection process and a table of the final articles used in the review would have been a

useful addition to this article although this publication does not request these tables and

they are not present in other reviews published by this journal. Themes are identified from

the selected papers and recommendations for interventions to combat bullying behaviours

were produced from the literature.

The book 'Working with Bereavement' published in 2014 is based on reviews of the

literature related to the various topics covered in the text. However it is not formulated as a

literature review in terms of explaining the methodological details of the literature search

for each topic reviewed.

The aim of the book is to provide a practical guide for a range of practitioners working with

people at the end of life and those bereaved. It is not an academic paper on

methodological aspects of literature reviews. As an applied researcher my focus is on

producing information which can equip the reader with a combination of knowledge and

skills for working in the area of bereavement. This is done through exploring key theories

and models, communication skills and practical and professional issues. The exercises of

self-reflection and applied examples found throughout the book are to support the reader

in their understanding.

36

Different types of bereavement are covered along with spiritual and cultural influences and

there is a section on self-care including issues of emotional labour and emotional

intelligence, vicarious trauma and coping strategies.

Although this publication is a practical handbook for those working in this area of care it

also contains theories and the evidence base for the practices and guidance given.

37

3 Original Independent Contribution

This final section provides a discussion of the key methodological, empirical and

conceptual contributions to knowledge made by this body of work. The original

contribution to knowledge represented in the submitted published works focusses on the

emotional aspects of nursing in relation to working hours, particularly concerning shifts,

responses by nurses to patient death, and how aspects such as emotional intelligence

along with other strategies are utilised and can be developed to help staff manage their

emotions in a healthcare setting. There follows an account of the contributions to

knowledge and the impact of all the submitted publications

3.1 The impact of shift patterns on healthcare professionals

Publishing this paper in the Journal of Nursing Management (2002) provided

recommendations for working practices to help reduce the negative effects of shift work on

staff. This paper has been quoted in a range of other studies and provides background

information on how shift work can impact on the physical, social and emotional aspects of

workers lives.

At a local level in the hospital where this study was conducted these recommendations

were implemented to help staff manage their working hours and provide managers with

information to assist them in planning their shift work schedules. Findings from this study

were also presented both locally and nationally at nursing conferences.

As a result of this publication I was invited to be part of a national group looking at how to

more effectively manage shift work in nursing and other areas of healthcare. This

demonstrates the impact of this research, and from the evidence collected the national

38

group produced guidance for managers regarding shift times and length to help advise

them in this aspect of their role.

Although studies into the effects of shift work have been carried out in a range of settings

since this publication, this study is still quoted in academic papers studying this aspect of

work (Peters et al., 2016; Lin et al., 2014; von Treuer et al., 2014). The findings are still

acknowledged as being relevant to practice today thus making an original contribution to

knowledge.

3.2 Effects of patient death on nursing staff: a literature review and account of the

research into ward staff experiences of patient death.

The literature review was published in the British Journal of Nursing (2011) and an

account of the research was published in the Nursing Standard (2014). Following

publication I was contacted by some clinically based nurses in the south of England and in

Scotland and supplied further information of the study regarding recommendations for

supporting staff to be used in their practice. This demonstrated that the choice of journal

for publication was advantageous in reaching the staff group I was hoping would read this

study, which was staff working in clinical practice and their managers, and shows the

impact of this research. My paper was addressing a clinical need. I presented this study at

the following conferences where it was well received:

European Conference in Nursing Science, Berlin (2010),

National Conference on Bereavement in a Healthcare Setting, Dundee (2010)

The Royal College of Nursing International Research Conference, Belfast (2011)

Sigma Theta Tau International, Phi Mu Chapter Inaugural Conference,

Bournemouth (2013)

39

3.3 Working with Bereavement: a practical guide

Following publication of this book I gave a presentation at the 'Off the Shelf' literature

festival in Sheffield (2015) outlining some key aspects from the book. Following the

presentation I responded to invitations from South Yorkshire Housing and Age Concern to

talk to members of their staff who support people in sheltered housing who have been

bereaved.

This book is a recommended text used by SHU and other universities for courses and

modules concerned with bereavement issues.

The book was reviewed by other academic nursing staff and professional journals.

Reviews of this book include the following:

'Working with bereavement is an excellent practical guide that covers a vast array of

subject matter from theories of bereavement, working with bereavement to hard to talk

about deaths.'

Ibadete Fetahu, Nursing Times

'Janet Wilson has produced a supremely practical book on bereavement. As a nurse,

psychotherapist and academic, the author offers readers from different professions

invaluable insights into bereavement work. No relevant reading list can afford not to

include this excellent book.'

Colin Feltham, Emeritus Professor, Sheffield Hallam University, and Associate

Professor of Humanistic Psychology, University of Southern Denmark.

40

'I am delighted to commend this book. Nurses, allied health professionals and

counsellors working in the field will find much to stimulate their thinking. It is an essential

read for those working with bereavement.'

Amanda Clarke, Professor of Nursing, Northumbria University, UK

'Working with bereavement' provides a comprehensive, yet thought provoking, overview

of issues that will help practitioners support people both practically and emotionally

when there has been some form of life related loss. The book recognises the complexity

of loss and grief, but the use of applied examples will help practitioners think about the

people and contexts where bereavement support can help. The book makes a

particularly important contribution to the field of bereavement work by incorporating

chapters on Hard to Talk About Deaths and Unrecognised Grief. The inclusion of

Reflection activities (Over to You) and a Self-Care chapter will help practitioners make

real connections from theory to the real world situations in which they are supporting

others.'

Professor Josie Tetley, Manchester Metropolitan University, UK

These references attest to the contribution to better inform practice that the book has

made.

3.4 The awareness of emotional intelligence by nurses and support workers in an

acute hospital setting.

An academic article on Emotional Intelligence in nursing was published in the Journal of

Health Sciences (2014) identifying that this was not a concept recognised by many

nursing staff working in clinical practice. Other articles on this topic focussed on emotional

41

intelligence in students and exploring this concept in relation to Registered nurses and

support workers provided an original contribution to knowledge in this field.

From writing this article I recognised that emotional intelligence was not a topic taught in

the undergraduate nurse training programme here at SHU. As a result the development

and use of emotional intelligence was added to the psychological sciences modules of the

course. Following this publication on Emotional Intelligence I was contacted by nurse

lecturers from two universities in the UK and we shared the content of our teaching

sessions on this topic to enhance our teaching resources. This again demonstrating the

applied value and impact of my work in nursing.

A paper on this topic was presented at the following conference:

Sigma Theta Tau International Phi Mu Chapter Biennial Conference, Leeds

(2015)

3.5 Professional socialisation and bullying behaviours in nursing

An article on Professional Socialisation in Nursing was published in the American

Research Journal of Nursing (2016) and an article on bullying behaviours, in nursing in the

British Journal of Nursing (2016). The paper on professional socialisation focussing on

nursing staff working in clinical practice again provided an original contribution to

knowledge in this area as previous papers mostly focussed on experiences of students in

relation to this concept. The publication on bullying supports previous publications on this

type of behaviour, and demonstrates that this is still an ongoing issue in clinical practice.

Following these publications teaching sessions were introduced for student nurses at SHU

on the topics of professional socialisation and bullying in nursing. This includes

discussions on how to manage these issues and is an important feature of seminar

42

discussions for year three students in the module they study on leadership and

management in nursing. In this way I continue to apply the findings from my research.

A paper on professional socialisation was presented at the following conference:

The Royal College of Nursing International Research Conference,

Glasgow (2014)

3.6 Service evaluation of a hospice at home service

The results were written up as a report for the local health trust enabling them to apply for

continued and increased funding. The results of the evaluation locally were that the

hospice at home service received funding to increase this service in terms of hours in the

day it was available and also to extend the fixed term funding which was scheduled to end

after two years.

The study was published in the British Medical Journal (BMJ) End of Life Journal (2015).

The choice of journal was made through exploring publications which focussed on

palliative and end of life care with the aim of making this article accessible to those

working in this speciality of healthcare. The design of this study and the inclusion of the

wide range of stakeholders had not been identified before; therefore this was an original

contribution to knowledge in the method used to evaluate this service.

The Vice Chairman for the National Association for Hospice at Home contacted the team

who conducted this evaluation to ask if our paper could be circulated around its

membership with a recommendation to use the study design we had developed in other

similar studies. This use of the study design indicates another contribution to knowledge

albeit this time to the development of future research studies.

43

3.7 Conclusion

I am an applied researcher in clinical practice and the research in this submission has

made original contributions to knowledge in terms of how nurses are supported in the

workplace, their understanding of the impact of patient death and how to best manage

these aspects of their work.

In addition my research has resulted in significant changes to the content of nursing

courses, particularly the inclusion of the topics of emotional intelligence and professional

socialisation which were not previously included in courses but are now part of the

curriculum.

From the research reported here, it is apparent that my original contribution to knowledge

is centred on understanding the emotional impact of nursing on staff and also on

equipping student nurses with the knowledge and skills they need for professional

practice. My research has also produced good clinical applied guidance, particularly in

relation to dealing with patient death, which is evidence based and which I have used my

research skills to produce.

In the applied area of nursing my focus has been to undertake and disseminate the

findings from applied research to the clinical and academic communities.

44

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Appendix 1: Origins and progression of the programme of study

My interest and involvement in research started before the dates of the studies selected

for this submission and have contributed to the development of my knowledge and skills in

this area. Both in my academic studies and my clinical work as a nurse I have always

been interested in the evidence base for clinical practices and have used opportunities to

explore and investigate clinical issues. I have also aimed to produce results from these

studies which can be used in practice settings for the benefit of both patients and staff.

From being a newly qualified staff nurse

I had an interest and concern for the emotional wellbeing and support available to nursing

staff. This developed as I realised the emotional impact of nursing work and that by

supporting staff and developing their knowledge and skills in this area then they were able

to provide a better level of care to patients and also support themselves and colleagues.

My first experience of research occurred whilst I worked in an Infectious diseases unit

where I questioned the current practice of wearing long sleeved cotton gowns as I thought

this was not an adequate protection and that plastic aprons would be more suitable. This

motivated me to search the literature and explore practices in other healthcare settings

which I did in America and Canada through a scholarship from Westfield Health. Resulting

from the report of this study the policy on protective clothing where I worked was changed

from wearing cotton gowns to the use of plastic aprons and I published this study in the

Nursing Times (1990).

As I progressed through my career I looked at how I could support clinical staff in their

working environment and explored the impact of various aspects such as shift work and

stressful events and how these could be better managed to reduce the emotional impact

on staff.

57

At this time I was also involved in voluntary work with a charity supporting the bereaved

and undertook courses in counselling becoming a trainer and supervisor in this area of

work. This culminated in an MSc in Integrative Psychotherapy and through my work as a

supervisor I wanted to research how best to support staff working particularly with patients

at the end of life and their families.

This study led to me focussing on various findings from this study and the writing of the

book ' Working with Bereavement', a handbook for practitioners caring for people at the

end of life and supporting those who are bereaved in a range of circumstances and

settings. It is aimed primarily at those working in health and social care with an emphasis

on application to clinical practice.

58

Appendix 2: Summary of submitted publications

1. Wilson J. (2002). The impact of shift patterns on Health Care Professionals.

Journal of Nursing Management, 10, 211-219.

This article was written at a time when the length of shifts in hospitals for nursing staff

were mostly 7.5hours and the impact of these on staff in a range of workplace settings

was being reviewed. I was involved in work reviewing staffing levels and the skillmix

required in certain clinical areas. Many areas in healthcare necessitate staff working over

a 24 hour period and the aim was to discover how this could be achieved to meet the

requirements of the service and have the least effect on the health and wellbeing of staff.

The cardiac unit in this hospital at that time operated a 7.5hour shift system and the

purpose of this research was to explore the possible benefits or issues of working 12hour

shifts. The hospital funded this study with a £2,000 grant. A phenomenological approach

was used to interview staff in order to identify their experiences of the physical, social and

emotional effects of shift work.

2. Wilson J, Kirshbaum M. (2011). Effects of patient death on nursing staff: a

literature review. British Journal of Nursing, 20(4), 239-241.

The purpose of this paper was to provide a grounding for a study into the effects on

nursing staff of patient death. It reviewed the current literature on this subject at the time.

This study consisted of a systematic search of the literature using a range of terms and

the focus was the effects of patient death on nursing staff and not on grief issues of other

professionals, patients or family members. Five themes were identified from the literature:

the theoretical context; the emotional impact on staff; the culture of the work environment;

personal life experiences of staff and coping strategies.

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3. Wilson J. (2014). Ward Staff experiences of patient death in an acute medical

setting. Nursing Standard, 28(37), 37-45.

The purpose of this paper was to report the findings from a Heideggarian

phenomenological study involving interviewing nursing staff about their experiences

following patient deaths in medical wards caring for people with respiratory diseases.

Phenomenology was an appropriate methodology as it was the personal experiences of

the participants which were sought in this study. Three main themes were identified;

responses, influences and support.

4. Wilson J. (2014). The Awareness of Emotional Intelligence by Nurses and Support

Workers in An Acute Hospital Setting. Journal of Health Sciences, 2(9), 458-464.

This paper focuses on one aspect of the findings from the above study. Although emotional

intelligence is recognised as an essential requirement for nursing (Cadmen & Brewer,

2001) a consistent theme arising from this study was the lack of awareness of this concept

amongst the participants. There was also a lack of knowledge of how this could be used to

effectively manage their emotions in handling stressful situations involving colleagues,

patients and relatives. Some participants did identify strategies they used to control their

stress but did not recognise this as emotional intelligence. The study identified that there

were differences between the responses of Registered nurses and healthcare support

workers in this area. Registered nurses reported being pro-active in seeking out colleagues

to talk to or sharing their emotions with others whereas some support workers said they did

not realise they were affected by a death at work until family members commented on

changes in their behaviour or attitudes when in their home environment.

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5. Wilson J. (2014). Working with Bereavement. A Practical Guide. Basingstoke:

Palgrave Macmillan.

The development of the book 'Working with Bereavement' started from the literature

review on the effects of patient death on nursing staff. This led to an exploration of

evidence for best practice in other areas of bereavement and end of life care. This book

provides evidence based practice from a library based research study of systematic

reviews and complementary work already done in this area. The book is aimed at a range

of professionals working in health and social care as well as those working in the voluntary

sector supporting both those at the end of life and those who are bereaved.

6. Wilson J., Steers J., Steele K., Turner J., Tinker A. (2015). Evaluation of

Community based Palliative Care and a Hospice at Home Service involving the use

of Focus Groups. End of Life Journal. Published Online First. [10August 2015] doi:

10.1136/eoljnl-2015-000004

As a result of my knowledge and experience in end of life care and bereavement I was

asked along with colleagues to undertake an evaluation of a hospice at home service in a

local town. The purpose of this study was to evaluate the hospice at home service which

had been in place for two years and to make recommendations for the future of this

service. This was a qualitative study consisting of focus groups with a range of

stakeholders and data analysis used a framework approach to categorise the responses.

The key stakeholders were made up of four groups; patients and carers, community

nursing staff, palliative care nurse specialists, and General Practitioners and senior

healthcare managers. The views of the different stakeholders were required to enable all

those affected by the service to be identified and given the opportunity to express their

opinions and describe their experiences. In the findings, participants identified that

61

important aspects of end of life care such as quick access to hospice at home services

and the prevention of admissions to hospital were being met by the service. Issues

requiring improvement were communication between hospital and community services,

educational and training needs regarding the use of technology and the limitation of the

current system which was not available overnight.

Several recommendations were made for the future of this service. One of these was the

need for education in the areas of technology use, breaking bad news and advanced care

planning. Another was a review of the communication system between the acute hospital

and community services and the clarification of roles of the different nursing staff groups.

There were a range of nurses including community nurses, Macmillan nurses, palliative

care nurses and other specialist nurses who were not always clear of their distinct roles

and responsibilities with particular patients and families. A major recommendation was

that the current service should be extended to a 24 hour service over 7 days to ensure

patients were able to access this service at any time of the day or night.

The study concluded that this service led to better service provision for patients

particularly in terms of prompt symptom relief and care interventions and also provided

support and advice to carers and to other community healthcare staff. This enabled

advanced care planning to be carried out earlier than previously and improved the

availability of resources for patients to be cared for in their preferred place of care.

62

7. Wilson J. (2016). Professional Socialization in Nursing; Experiences of New and

Established Nursing Staff in response to patient death. American Research Journal

of Nursing, 2(1), 4-8.

The purpose of this paper was to explore further an aspect from a larger study of how

professional socialisation affected new and established nursing staff in terms of their

response to patient death.

Professional socialisation is the acquisition of behaviours, values, and attitudes required to

fulfil a professional role (Shinyashiki, Mendes, Trevizan & Day, 2006). Feng and Tsai

(2012) identified that a sense of belonging is very important to newly qualified nurses and

that they will conform to perceived norms in order to feel part of the team in which they

work.

The design of this study was a Heiddegarian phenomenological approach which was

appropriate as it was the personal experiences of the participants which were sought. The

issue of professional socialisation was identified as significant for newly qualified nurses in

particular. Participants in this study who were newly qualified reported feeling they should

not show their emotions or discuss their feelings with colleagues as they perceived that

this was a norm they needed to adhere to in order to be accepted by more established

staff on the ward.

The findings form this study identified that some of the more experienced nurses on the

ward did show their emotions and talked about their feelings with colleagues, reporting

benefits for themselves and colleagues of sharing their experiences and both giving and

receiving support.

These differences in behaviour could be due to experienced nurses feeling secure and

comfortable in their professional roles and being clear on the values they hold. The more

inexperienced nurses could be lacking in both knowledge and skills as well as being

63

unsure of their professional role. This study concluded that some newly qualified staff

made assumptions about the beliefs and attitudes of more established staff members

which were incorrect. Opportunities for newer staff members to discuss expectations and

practices with more experienced colleagues could help them develop constructive

strategies for managing their emotions around patient death and more openness in talking

about this issue could improve staff relationships leading to more effective team working.

8. Wilson J. (2016). An Exploration of Bullying Behaviours in Nursing: a review of

the literature. British Journal of Nursing, 25(6), 2-5.

This paper was developed from the previous one on professional socialisation. It became

apparent when researching for the above paper that in some healthcare settings, if new

staff did not conform to the norms of a particular area then bullying behaviours were used

to try to force staff to follow the customs and practices of that setting. Bullying is defined

as intentional and repeated psychological violence, having the effect of humiliating and

isolating staff from colleagues (Rodwell & Demir, 2012).

As long ago as 1986 bullying behaviours were raised as an issue in nursing by Meissner

and current literature (Pearce, 2017) reports that almost a quarter of respondents to a

recent NHS staff survey had experienced bullying and harassment in the previous year.

This paper consisted of a systematic search of the literature to discover the incidence of

bullying behaviours both at the present time and in the past, and over a range of settings

in the United Kingdom and other countries. It was discovered that this is an international

issue with reports from a range of countries including Australia (Hegney, Tuckett, Parker &

Eley, 2010), Brazil (Cahu, daCosta, Pinto-Costa, Batista & Batista, 2014), Canada

(Duncan et al., 2001) and Turkey (Yildirim, 2009). Bullying behaviours reported in these

studies were common to all areas and included staff having their opinions ignored, being

64

given impossible targets, humiliated or ridiculed in their work, and being given trivial or

unpleasant tasks (Carter et al., 2013).

Perpetrators of bullying were mostly those in a senior position to the person being bullied

or established staff members in a particular healthcare setting (Sauer, 2012).

The impact of bullying was identified as leading to staff feeling isolated, insecure, fearful

and not valued (Burnes & Pope, 2007). Sauer (2012) found that this behaviour could not

only lead to staff leaving their job but also leaving the profession.

65

Appendix 3: van Manens approach to data analysis as used in the empirical study on

ward staff responses to patient death

Following the first interviews the recordings were transcribed, and using the computer

software programme Nvivo, the frequency of commonly used words and phrases were

found. These were then be analysed using what van Manen (1984 and 1990) describes as

‘conducting thematic analysis’. The transcripts were initially read in their entirety in order to

gain an overall understanding. They were then read and reread repeatedly and statements

or phrases, which appeared to be revealing or essential about the experience, highlighted

(described as ‘uncovering aspects in life world’). The transcripts were compared with each

other identifying common themes and differences. A collection of phrases were produced

and written on the cards to be used in the second interviews with commonalities amongst

the descriptions given by the various participants.

At the second interviews the phrases derived from the transcripts were presented to the

participants who were asked to scrutinise them to identify words and phrases, which were

important to them. Participants were asked to discard cards which they did not think were

relevant or applicable. They then divided the remaining cards into groups of their own

choosing and gave the groups names indicating how they perceived them as being related

to each other in some way. A strategy of comparative analysis was used by the researcher

to organise and seek relationships between the groups and to identify emerging themes.

This involved repeatedly studying and comparing the groups formed by the participants

and clustering the groups into connecting themes. Schematic diagrams were used to

identify connections with headings and related quotes grouped together. The researcher’s

knowledge provided insight to enable the correct identification of the information.

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Finally, the researcher reviewed and re-reviewed the preliminary themes to determine the

three essential ones described as ‘responses’, ‘influences’ and ‘support’, and which

answered the research questions posed by the first three objectives of the study.